Endoscopic Third Ventriculostomy

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Endoscopic Third Ventriculostomy, it's an effective technique for opening the CSF pathways at the level of the floor of the third ventricle. And treating obstructive hydrocephalus proximal to the aqueduct. This is a 63 year old female with gait instability found to have triventricular hydrocephalus aqueductal stenosis. A right frontal burr hole was performed. The patient is in a supine position. Neuronavigation was used. This burr hole is just anterior to the Connell suture. A linear incision was used. Planning was performed based on neuronavigation. Here, the peel-away sheath was used to cannulate the ventricle, while the Axium small Neuroendoscope is within the peel-away sheath. The sheath has to be exactly perpendicular to their scalp, or the skull here, it's angulated. So we use neuronavigation and the perpendicular angle, as you can see here, to cannulate the ventricle. the peel-away sheath should not be inserted deeper to injure the fornix or other structures within the ventricle. Next, the stylet of the peel-away sheath is removed, the endoscope is introduced, and the ventricle is entered, As you can see here. Then the sheath is peeled away and stapled to the scalp. And now we'll start or interventricular work. Here's the celateral ventricle. Entering the third ventricle, you can see the floor. Just entered to the mammillary bodies here. The endoscopic grasper is used to create the hole in multiple different reactions. Usually 90 degrees apart. It's opened and then withdrawn to avoid any vascular injury. Endoscope is then introduced within the interpeduncular cisterns to assure good patency of the ostium. And then again, different directions may be used via the grasper to create a bigger hole as necessary. And here's the final product. You can see a reasonable size ostium exposure and entry all the way into the interpeduncular cisterns. The basil artery and its capit is evident. And the free flow of CSF is demonstrated. Overall, this is a very efficacious technique to avoid ventricular peritoneal shunting when possible. Thank you.

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